An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.